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Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS < 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.
Pathological gambling is a behavioural addiction with negative economic, social, and psychological consequences. Identification of contributing genes and pathways may improve understanding of aetiology and facilitate therapy and prevention. Here, we report the first genome-wide association study of pathological gambling. Our aims were to identify pathways involved in pathological gambling, and examine whether there is a genetic overlap between pathological gambling and alcohol dependence.
Four hundred and forty-five individuals with a diagnosis of pathological gambling according to the Diagnostic and Statistical Manual of Mental Disorders were recruited in Germany, and 986 controls were drawn from a German general population sample. A genome-wide association study of pathological gambling comprising single marker, gene-based, and pathway analyses, was performed. Polygenic risk scores were generated using data from a German genome-wide association study of alcohol dependence.
No genome-wide significant association with pathological gambling was found for single markers or genes. Pathways for Huntington's disease (P-value = 6.63 × 10−3); 5′-adenosine monophosphate-activated protein kinase signalling (P-value = 9.57 × 10−3); and apoptosis (P-value = 1.75 × 10−2) were significant. Polygenic risk score analysis of the alcohol dependence dataset yielded a one-sided nominal significant P-value in subjects with pathological gambling, irrespective of comorbid alcohol dependence status.
The present results accord with previous quantitative formal genetic studies which showed genetic overlap between non-substance- and substance-related addictions. Furthermore, pathway analysis suggests shared pathology between Huntington's disease and pathological gambling. This finding is consistent with previous imaging studies.
Despite established clinical associations among major depression (MD), alcohol dependence (AD), and alcohol consumption (AC), the nature of the causal relationship between them is not completely understood. We leveraged genome-wide data from the Psychiatric Genomics Consortium (PGC) and UK Biobank to test for the presence of shared genetic mechanisms and causal relationships among MD, AD, and AC.
Linkage disequilibrium score regression and Mendelian randomization (MR) were performed using genome-wide data from the PGC (MD: 135 458 cases and 344 901 controls; AD: 10 206 cases and 28 480 controls) and UK Biobank (AC-frequency: 438 308 individuals; AC-quantity: 307 098 individuals).
Positive genetic correlation was observed between MD and AD (rgMD−AD = + 0.47, P = 6.6 × 10−10). AC-quantity showed positive genetic correlation with both AD (rgAD−AC quantity = + 0.75, P = 1.8 × 10−14) and MD (rgMD−AC quantity = + 0.14, P = 2.9 × 10−7), while there was negative correlation of AC-frequency with MD (rgMD−AC frequency = −0.17, P = 1.5 × 10−10) and a non-significant result with AD. MR analyses confirmed the presence of pleiotropy among these four traits. However, the MD-AD results reflect a mediated-pleiotropy mechanism (i.e. causal relationship) with an effect of MD on AD (beta = 0.28, P = 1.29 × 10−6). There was no evidence for reverse causation.
This study supports a causal role for genetic liability of MD on AD based on genetic datasets including thousands of individuals. Understanding mechanisms underlying MD-AD comorbidity addresses important public health concerns and has the potential to facilitate prevention and intervention efforts.
The dynamic response of structured materials, such as regular lattices, is nontrivial partly due to the interaction of mechanical waves throughout the structure and free surfaces as the material is dynamically compressed. The existence of an elastic precursor wave in additively manufactured lattices was recently shown to match theoretical predictions and simulation results. Following up on this work, we have investigated the behavior of the elastic precursor with propagation distance, impact speed, and impact material. Through a series of gas gun experiments coupled to X-ray phase contrast imaging measurements and complementary simulations, the elastic precursor wavespeed appears to be nearly independent of impact speed and impact material. We observed evidence for the sustained elastic wave propagation through many unit cells at four significantly different impact conditions. We compared these results with direct numerical simulations of the experiments and found good agreement.
This article introduces a special volume of Advances in Archaeological Practice dedicated to the interpretation and presentation of archaeology. It provides an overview of several essays that came out of a session at the European Association of Archaeology Conference in 2017, which focused upon how interpretation can be implemented within daily practices of (cultural resource management) archaeology in a way that provides heritage value. We bring the arguments together into a call for a creative, interpretive archaeology that does not take compliance or academic publications as its end goal but will speak to a far wider range of audiences through the development and presentation of stories and narratives that truly engage and inspire people. We argue that this can be achieved by implementing “emotion design” methods that dynamically differentiate between information, message, emotion, and media, by working closely together with creatives, interpretive experts, communities, and partners and, ultimately, by integrating interpretation firmly at the core of planning processes, archaeological workflows, and our daily practices.
Background: Continuous video-EEG (cvEEG) monitoring is the standard of care for diagnosis and management of neonatal seizures. However, it is labour-intensive. We aimed to establish consistency in monitoring of newborns utilising NICU nurses. Methods: Neonatal nurses were trained to apply scalp electrodes, troubleshoot technical issues. Guidelines, checklists and visual training modules were developed. A central network system allowed remote access to the cvEEGs by the epileptologist for timely interpretation and feedback. We compared 100 infants with moderate to severe HIE before and after the training program. Results: 192 cvEEGs were performed. Of the 100 infants compared; time to initiate brain monitoring decreased by average of 31.5 hours, in electrographic seizure detection increased(20% compared to 34% a), seizure clinical misdiagnosis decreased (65% compared to 36% ), and Anti-Seizure burden decreased. Conclusions: Training experienced NICU nurses to set-up, start and monitor cvEEG can decrease the time to initiate cvEEG which may lead to better seizure diagnosis and management.
Background: Despite advances in neonatal care, neonates with moderate to severe HIE are at high risk of mortality and morbidity. we report the impact of a dedicated NNCC team on short term mortality and morbidities. Methods: A retrospective cohort study on neonates with moderate to serve HIE between July 1st 2008 and December 31st 2017. primary outcome : a composite of death and/or brain injury on MRI. Secondary outcomes: rate of cooling, length of hospital stay, anti-seizure medication burden, and use of inotropes. A regression analysis was done adjusting for gestational age, birth weight, gender, out-born status, Apgar score at 10 minutes, cord blood pH, and HIE clinical staging Results: 216 neonates were included, 109 before NNCC implementation, and 107 thereafter. NNCC program resulted in reduction in the primary outcome (AOR: 0.28, CI: 0.14-0.54, p<0.001) and brain injury (AOR: 0.28, CI: 0.14-0.55, p<0.001). It decreased average length of stay/infants by 5 days (p=0.03), improved cooling rate (73% compared to 93% , p <0.001), reduced: seizure misdiagnosis (71% compared to 23%, P <0.001), anti-seizure medication burden (P = 0.001), and inotrope use (34% compared to 53%, p=0.004) Conclusions: NNCC program decreased mortality and brain injury , shortened the length of hospital stay and improved care of neonates with significant HIE.
Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings.
A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals.
Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers’ involvement in the implementation differed between the units.
Significance of the results
The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.
Psychosocial therapy after deliberate self-harm might be associated with reduced risk of specific causes of death.
In this matched cohort study, we included patients, who after an episode of deliberate self-harm received psychosocial therapy at a Suicide Prevention Clinic in Denmark between 1992 and 2010. We used propensity score matching in a 1:3 ratio to select a comparison group from 59 046 individuals who received standard care. National Danish registers supplied data on specific causes of death over a 20-year follow-up period.
At the end of follow-up, 391 (6.9%) of 5678 patients in the psychosocial therapy group had died, compared with 1736 (10.2%) of 17 034 patients in the matched comparison group. Lower odds ratios of dying by mental or behavioural disorders [0.54, 95% confidence interval (CI) 0.37–0.79], alcohol-related causes (0.63, 95% CI 0.50–0.80) and other diseases and medical conditions (0.61, 95% CI 0.49–0.77) were noted in the psychosocial therapy group. Also, we found a reduced risk of dying by suicide as well as other external causes, however, not by neoplasms and circulatory system diseases. Numbers needed to treat were 212.9 (95% CI 139.5–448.4) for mental or behavioural disorders as a cause of death, 111.1 (95% CI 79.2–210.5) for alcohol-related causes and 96.8 (95% CI 69.1–161.8) for other diseases and medical conditions.
Our findings indicate that psychosocial therapy after deliberate self-harm might reduce long-term risk of death from select medical conditions and external causes. These promising results should be tested in a randomized design.
Approximately half of the variation in wellbeing measures overlaps with variation in personality traits. Studies of non-human primate pedigrees and human twins suggest that this is due to common genetic influences. We tested whether personality polygenic scores for the NEO Five-Factor Inventory (NEO-FFI) domains and for item response theory (IRT) derived extraversion and neuroticism scores predict variance in wellbeing measures. Polygenic scores were based on published genome-wide association (GWA) results in over 17,000 individuals for the NEO-FFI and in over 63,000 for the IRT extraversion and neuroticism traits. The NEO-FFI polygenic scores were used to predict life satisfaction in 7 cohorts, positive affect in 12 cohorts, and general wellbeing in 1 cohort (maximal N = 46,508). Meta-analysis of these results showed no significant association between NEO-FFI personality polygenic scores and the wellbeing measures. IRT extraversion and neuroticism polygenic scores were used to predict life satisfaction and positive affect in almost 37,000 individuals from UK Biobank. Significant positive associations (effect sizes <0.05%) were observed between the extraversion polygenic score and wellbeing measures, and a negative association was observed between the polygenic neuroticism score and life satisfaction. Furthermore, using GWA data, genetic correlations of -0.49 and -0.55 were estimated between neuroticism with life satisfaction and positive affect, respectively. The moderate genetic correlation between neuroticism and wellbeing is in line with twin research showing that genetic influences on wellbeing are also shared with other independent personality domains.
Delayed feed and water access is known to impair growth performance of day old broiler chickens. Although effects of feed access on growth performance and immune function of broilers have been examined before, effects of dietary composition and its potential interaction with feed access are hardly investigated. This experiment aimed to determine whether moment of first feed and water access after hatch and pre-starter composition (0 to 7 days) affect growth rate and humoral immune function in broiler chickens. Direct fed chickens received feed and water directly after placement in the grow-out facility, whilst delayed fed chickens only after 48 h. Direct and delayed fed chickens received a control pre-starter diet, or a diet containing medium chain fatty acids (MCFA) or fish oil. At 21 days, chickens were immunized by injection of sheep red blood cells. The mortality rate depended on an interaction between feed access and pre-starter composition (P=0.014). Chickens with direct feed access fed the control pre-starter diet had a higher risk for mortality than chickens with delayed feed access fed the control pre-starter diet (16.4% v. 4.2%) whereas the other treatment groups were in-between. BW gain and feed intake till 25 days in direct fed chickens were higher compared with delayed fed chickens, whilst gain to feed ratio was lower. Within the direct fed chickens, the control pre-starter diet resulted in the highest BW at 28 days and the MCFA pre-starter diet the lowest (Δ=2.4%), whereas this was opposite for delayed fed chickens (Δ=3.0%; P=0.033). Provision of MCFA resulted in a 4.6% higher BW gain and a higher gain to feed ratio compared with other pre-starter diets, but only during the period it was provided (2 to 7 days). Minor treatment effects were found for humoral immune response by measuring immunoglobulins, agglutination titers, interferon gamma (IFN-γ), and complement activity. Concluding, current inclusion levels of fish oil (5 g/kg) and MCFA (30 g/kg) in the pre-starter diet appear to have limited (carryover) effects on growth and development, as well as on humoral immune function.
Generally, there is a need for short questionnaires to estimate diet quality in the Netherlands. We developed a thirty-four-item FFQ – the Dutch Healthy Diet FFQ (DHD-FFQ) – to estimate adherence to the most recent Dutch guidelines for a healthy diet of 2006 using the DHD-index. The objectives of the present study were to evaluate the DHD-index derived from the DHD-FFQ by comparing it with the index based on a reference method and to examine associations with participant characteristics, nutrient intakes and levels of cardiometabolic risk factors. Data of 1235 Dutch men and women, aged between 20 and 70 years, participating in the Nutrition Questionnaires plus study were used. The DHD-index was calculated from the DHD-FFQ and from a reference method consisting of a 180-item FFQ combined with a 24-h urinary Na excretion value. Ranking was studied using Spearman’s correlations, and absolute agreement was studied using a Bland–Altman plot. Nutrient intakes derived from the 180-item FFQ were studied according to quintiles of the DHD-index using DHD-FFQ data. The correlation between the DHD-index derived from the DHD-FFQ and the reference method was 0·56 (95 % CI 0·52, 0·60). The Bland–Altman plot showed a small mean overestimation of the DHD-index derived from the DHD-FFQ compared with the reference method. The DHD-index score was in the favourable direction associated with most macronutrient and micronutrient intakes when adjusted for energy intake. No associations between the DHD-index score and cardiometabolic risk factors were observed. In conclusion, the DHD-index derived from the DHD-FFQ was considered acceptable in ranking but relatively poor in individual assessment of diet quality.
Nutrient-rich food (NRF) index scores are dietary quality indices based on nutrient density. We studied the design aspects involved in the development and validation of NRF index scores, using the Dutch consumption data and guidelines as an example. We evaluated fifteen NRF index scores against the Dutch Healthy Diet Index (DHD-index), a measure of adherence to the Dutch dietary guidelines, and against energy density. The study population included 2106 adults from the Dutch National Food Consumption Survey 2007–2010. The index scores were composed of beneficial nutrients (protein, fibre, fatty acids, vitamins, minerals), nutrients to limit (saturated fat, sugar, Na) or a combination. Moreover, the influence of methodological decisions was studied, such as the choice of calculation basis (100 g or 100 kcal (418 kJ)). No large differences existed in the prediction of the DHD-index by the fifteen NRF index scores. The score that best predicted the DHD-index included nine beneficial nutrients and three nutrients to limit on a 100-kcal basis, the NRF9.3 with a model R2 of 0·34. The scores were quite robust with respect to sex, BMI and differences in calculation methods. The NRF index scores were correlated with energy density, but nutrient density better predicted the DHD-index than energy density. Consumption of vegetables, cereals and cereal products, and dairy products contributed most to the individual NRF9.3 scores. In conclusion, many methodological considerations underlie the development and evaluation of nutrient density models. These decisions may depend upon the purpose of the model, but should always be based upon scientific, objective and transparent criteria.
Wing flexibility is well established as providing gust rejection and delayed onset of stall for micro air vehicles. As such, many designs adopt wings of a flexible material mounted onto a skeleton comprised of a stiff leading-edge spar and stiff chordwise strips, called battens. These battens are shown to provide additional strength at localised regions of the wing and thus improve the gust rejection and delay stall; however, their effect on the flight dynamics is less studied. Using a numerical modeling approach, this paper explores a design space of vehicles with a varied number of wing battens mounted onto a baseline vehicle with a flexible wing. The battens are modelled as stepwise changes in torsional stiffness along the wing span. The resulting trim characteristics, static stability metrics and flight dynamics are evaluated. The battens are shown to improve gust rejection but otherwise have a complicated effect across the design space. A reduction in the number of battens improves the longitudinal static stability derivative slightly but lowers the lateral and directional static stability. The damping is decreased for the short period mode and increased for the phugoid and dutch roll modes as the number of battens is reduced.
Uteroplacental insufficiency resulting in intrauterine growth restriction has been associated with the development of cardiovascular disease, coronary heart disease and increased blood pressure, particularly in males. The molecular mechanisms that result in the programming of these phenotypes are not clear. This study investigated the expression of cardiac JAK/STAT signalling genes in growth restricted offspring born small due to uteroplacental insufficiency. Bilateral uterine vessel ligation was performed on day 18 of pregnancy to induce growth restriction (Restricted) or sham surgery (Control). Cardiac tissue at embryonic day (E) 20, postnatal day (PN) 1, PN7 and PN35 in male and female Wistar (WKY) rats (n=7–10 per group per age) was isolated and mRNA extracted. In the heart, there was an effect of age for males for all genes examined there was a decrease in expression after PN1. With females, JAK2 expression was significantly reduced after E20, while PI3K in females was increased at E30 and PN35. Further, mRNA expression was significantly altered in JAK/STAT signalling targets in Restricteds in a sex-specific manner. Compared with Controls, in males, JAK2 and STAT3 were significantly reduced in the Restricted, while in females SOCS3 was significantly increased and PI3K significantly decreased in the Restricted offspring. Finally, there were specific differences in the levels of gene expression within the JAK/STAT pathway when comparing males to females. Thus, growth restriction alters specific targets in the JAK/STAT signalling pathway, with altered JAK2 and STAT3 potentially contributing to the increased risk of cardiovascular disease in the growth restricted males.